It must be true I read it in the tabloids.

BACKGROUND: Previous attempts to improve the quality of health journalism have not led to more responsible reporting of health news. METHOD: We reviewed the front pages of three daily tabloid and three daily broadsheet UK newspapers during a 1 month period in 2017 for medical headlines in which claims were made for diets, lifestyle behaviours or drug therapies that influence health. RESULTS: Front page medical headlines were carried by the Daily Express (11), Daily Mail (two), Daily Mirror (one) and Daily Telegraph (one). Neither the Guardian nor the Independent carried medical stories on their front pages during the period of study. Eleven headlines suggested benefits and three suggested harm. One headline accurately reflected its source material, but in this instance the source material was of doubtful clinical relevance. The remaining 13 headlines either exaggerated benefit (seven), exaggerated harm (two) or made false claims (four). CONCLUSIONS: The cumulative effect of everyday misreporting of medical stories in UK newspapers may not only serve to confuse the public but also have serious consequences for public health.

Meta-analysis of statins in chronic kidney disease: who benefits?

BACKGROUND: Attempts to reduce the burden of vascular disease in advanced chronic kidney disease (CKD) by control of lipids have not been as successful as predicted. AIM: To determine the extent to which the effectiveness of statins varies by kidney class. DESIGN: Meta-analysis. METHODS: We selected randomized trials of statin vs. placebo that gave outcomes for CKD3 (eGFR 30-59 ml/min), CKD4 (eGFR 15-29 ml/min), CKD5 (eGFR < 15 ml/min)/5D(dialysis) and transplant patients separately. Data sources were the Cholesterol Triallists' Treatment Collaboration and previously published meta-analyses. Main outcome measures were major cardiovascular events (MACE), cardiovascular death and all-cause mortality (ACM). RESULTS: A total of 13 studies provided 19 386 participants with CKD3, 2565 with CKD4, 7051 with CKD5/5D and 2102 with a functioning renal transplant. Statins reduced MACE (pooled HR 0.72, 95% CI 0.67-0.78) and ACM (0.82, 0.73-0.91) in CKD3; probably reduced MACE (0.78, 0.62-0.99) in CKD4; and probably reduced cardiovascular death (0.62, 0.40-0.96) in renal transplants. There were no cardiovascular or ACM data in CKD4; there was no convincing evidence of benefit for any outcome in CKD5/5D; and no significant reduction in MACE or ACM in patients with a functioning transplant. CONCLUSIONS: Statins are indicated in CKD3, probably indicated in CKD4, not indicated in CKD5/5D and probably indicated in patients with a functioning transplant. Too few patients with CKD4 and renal transplants have been included in lipid lowering trials for confident conclusions to be drawn.

Management of post-operative acute kidney injury.

Post-operative acute kidney injury (AKI) is a common complication of surgery with significant short- and long-term adverse consequences. The adoption of diagnostic criteria for AKI (RIFLE, AKIN and KDIGO) has facilitated comparison of data reported by different centres, confirming that even mild AKI is associated with excess mortality. It remains unclear whether this is caused by the kidney injury itself or whether AKI is simply a marker of underlying disease severity. There is no trial evidence to support the use of any specific therapeutic intervention in post-operative AKI. Best current treatment is, therefore, preventative by optimizing hydration and avoidance of nephrotoxins, emphasizing the importance of earlier detection and identification of individuals at high risk for AKI. In this review, we examine the latest literature on the management of post-operative AKI in adult patients, specifically the diagnosis and definition of AKI, epidemiology and pathogenesis and risk stratification in cardiac and non-cardiac surgery. We also review the latest evidence on pharmacological and non-pharmacological interventions.

Adopting seven-day working in practice: a report by the Royal College of Physicians and Surgeons of Glasgow.

Following the UK Academy of Medical Royal Colleges Report on seven day consultant present care, the Royal College of Physicians and Surgeons of Glasgow held a symposium to explore clinicians' views on the ways in which clinical care should best be enhanced outside 'normal' working hours. In addition, a survey of members and fellows was undertaken to identify the tests which would make the greatest impact on care out of hours. Key messages were: (a) that seven-day consultant delivered care would not achieve the desired benefit to patient care if introduced in isolation from other inter-relating factors. These include alternatives to hospital admission, enhanced nursing support, increased junior medical, pharmacy, social care and ambulance availability and greater access to selected diagnostic services; (b) that the care of hospital inpatients is a service which is one part of the totality of secondary care provision. Any significant change in the deployment of staff for inpatient care must be carefully managed so as not to result in a reduced quality of care provided by the rest of the system.

The challenges of renal replacement therapy and renal palliative care in the elderly.

The main aim of this review is to let general practitioners and physicians understand what happens to older patients after referral to the renal service. Usually, most patients will be managed completely by the renal team, either because the patient requires dialysis or because conservative but specialised care is appropriate. The recent increase in dialysis rate can mostly be accounted for by older patients for whom such demanding treatment was previously thought to be contraindicated. The decision to dialyse the elderly still remains difficult, with recent data suggesting that if there are significant comorbidities the survival advantage of dialysis in patients over 75 years of age is unlikely to be more than four months. Towards the end of life, conservative treatment is not simply a decision not to dialyse, but comprises active disease management, including treatment of anaemia and other supportive care, which may become increasingly complex, e.g. pain relief with fentanyl and alfentanyl. Older patients who decide to accept dialysis treatment contend with all the usual end of life issues of older people. They have an additional option, denied to the rest of us, of dialysis withdrawal; this effectively allows them to die at a time of their choosing.

Rhabdomyolysis following co-prescription of fusidic acid and atorvastatin.

The placebo-corrected incidence of rhabdomyolysis in a systematic review of 20 statin trials was 1.6/100,000 per year. It is likely to be higher than this in everyday clinical practice when statins are knowingly or inadvertently co-prescribed with drugs that interfere with their metabolism. We report a case of rhabdomyolysis causing muscle weakness and prolonging an episode of dialysis-dependent acute kidney injury, which occurred when fusidic acid was co-prescribed with atorvastatin. Renal function and muscle power recovered when both drugs were withdrawn. We found four other cases of rhabdomyolysis with fusidic acid and atorvastatin and three with fusidic acid and simvastatin in the literature, a review of which suggests that the risks of rhabdomyolysis vary with the extent to which an individual statin is dependent for its metabolism on the cytochrome P450 3A4 isoenzyme and the degree to which this isoenzyme's activity is inhibited by a particular antimicrobial. Of note, the interaction between statins and fusidic acid did not feature in seven of eight recent reviews of statin toxicity. Our case report highlights the importance of close monitoring of patients on statins, especially when new drugs are started or if patients become unwell, by checking creatine kinase and liver function tests and by examining for new muscle weakness. Our review of statin-antimicrobial drug interactions suggests that fusidic acid is another CYP450 3A4 enzyme inhibitor with the potential to cause rhabdomyolysis when co-prescribed with simvastatin and atorvastatin.

Patient preferences for single rooms or shared accommodation in a district general hospital.

OBJECTIVES: To determine whether patients who have used a Scottish district general hospital would prefer single or shared accommodation on a future admission. METHODS: We surveyed 80 in-patients in January 2008 in order to obtain 20 medical and 20 surgical patients in single rooms and the same number in shared accommodation. Each patient received a seven point questionnaire that had been validated in another centre. RESULTS: Forty four men and 36 women, median 64 years, who had been in hospital for a median of 4.5 days (range 1 to 53 days) participated in the survey. Seventy per cent of patients in shared and 40% of patients in single rooms said they would prefer shared accommodation during a future hospital admission. Those expressing a preference for shared accommodation were older (median age 68 versus 58 years) and had been in hospital for longer (median 5.5 versus 3.5 days) than those who said they would prefer a single room. CONCLUSIONS: It is likely that the desire for company among older people who have to spend a week or more in hospital is driving the responses we obtained. Our findings do not support claims that the argument in favour of 100% single rooms is 'overwhelming'.

Comparison of combined urea and creatinine clearance and prediction equations as measures of residual renal function when GFR is low.

BACKGROUND: UK, US and European guidelines recommend the decision to initiate dialysis should be based on a combination of measurements of kidney function, nutritional status and clinical symptoms. Such recommendations assume an accurate and reproducible measure of glomerular filtration rate (GFR). METHODS: Prospective study of 97 patients with chronic kidney disease (CKD) and serum creatinine >200 micromol/l (2.26 mg/dl) who between them contributed 388 24 h urine collections. Our main outcome measure was the number of patients with low residual renal function identified by different tests, using widely accepted thresholds. We calculated sensitivity, specificity, positive and negative predictive values and receiver operating characteristic curves for each comparison using a combined urea and creatinine clearance of <15 ml/min to indicate the likely presence of end stage renal disease (CKD stage 5). RESULTS: Seventy five patients had a combined urea and creatinine clearance <15 ml/min during the study. Using the highest measurement of serum creatinine for each patient, the best of the prediction equations was the 4-variable modification of diet in renal disease (MDRD) equation (area under ROC curve 0.93). This was followed by Kt/V (AUC 0.91) and Cockroft Gault with and without correction for ideal body weight (AUC 0.89). Further analyses showed that the 4-variable MDRD equation had higher NPV (64%) but lower PPV (89%) than the other tests (NPV 40-49%, PPV 92-100%), for identifying patients whose combined clearance was <15 ml/min. CONCLUSION: The 4-variable MDRD formula is currently the best available prediction equation for GFR, but will nevertheless over estimate residual renal function when this is significantly impaired in up to 36% cases. Collection of 24 h urine samples may still have a role in the assessment of patients with stages 4 and 5 CKD.

Early and late mortality after myocardial infarction in men and women: prospective observational study.

OBJECTIVE: To compare characteristics, management, and outcome of myocardial infarction (MI) in men and women. DESIGN: Prospective observational study. SETTING: District general hospital in southwest Scotland. PARTICIPANTS: 966 men and 597 women admitted with first MI between 1994 and 2000 with follow up to the end of 2001. RESULTS: 393 (40.7%) men and 305 (51.1%) women died during a median follow up of 3.4 years for the survivors. Univariate analysis indicated an excess mortality among women (hazard ratio (HR) 1.45, 95% confidence interval (CI) 1.25 to 1.68), which disappeared after adjustment for age, smoking, co-morbidity, previous vascular disease, diabetes, hypertension, and social deprivation (HR 1.02, 95% CI 0.87 to 1.20). There was also an excess early mortality within 30 days among women (HR 1.54, 95% CI 1.20 to 1.98), though this did not retain significance after adjustment for the same covariates (HR 1.04, 95% CI 0.79 to 1.37). Small and insignificant differences were found in the proportion of men and women receiving thrombolysis on admission and secondary prophylactic drugs at discharge, except for statins and beta blockers, which were respectively more (adjusted odds ratio 1.48, 95% CI 1.10 to 1.98) and less (adjusted odds ratio 0.78, 95% CI 0.60 to 1.00) commonly prescribed to women. CONCLUSION: Results suggest that the poorer outcome for women after MI reported in other studies may reflect sex bias in management as well as differences in age and co-morbidity and support the view that if women have access to the same quality of care as men then survival will be the same.

Life threatening hyperkalaemia with diarrhoea during ACE inhibition.

A 67 year old woman developed acute renal failure with serum potassium 9.4 mmol/l requiring emergency dialysis after seven days of diarrhoea while taking an ACE inhibitor for vascular disease. Review of the literature, the British National Formulary, and the patient information leaflets for each of the 11 ACE inhibitors currently marketed in the UK suggests that this potentially life threatening complication of ACE inhibition is not yet widely recognised.

Diarrhoea, vomiting and ACE inhibitors:--an important cause of acute renal failure.

The occurrence of severe acute renal failure in 3 patients who developed diarrhoea while taking angiotensin converting enzyme (ACE) inhibitors led us to undertake a retrospective cohort survey to determine the frequency with which diarrhoea and vomiting are associated with acute renal failure in patients taking this class of drug. Serum creatinine was measured as part of the diagnostic workup of 2398 consecutive admissions to an acute medical receiving unit in a district general hospital. Outcome measures were the presence of diarrhoea and/or vomiting, and whether taking an ACE inhibitor, NSAID or diuretic at the time of admission, also previous, initial and follow up serum creatinine concentrations. Peak serum creatinine in the 3 cases was 1159, 989 and 765 micromol/l. None of the 3 required dialysis and all recovered renal function completely after receiving large volumes of intravenous fluid. In the cohort study, 89 of 2398(3.7%) admissions had serum creatinine >/=200 micromol/l. Nine were regular dialysis patients. Of the remaining patients, 30 (37.5%) were taking an ACE inhibitor. Six of 30 (20%) gave a history of diarrhoea and/or vomiting. Median creatinine concentration in this group was 135 (range 111-209) micromol/l before admission, 292 (216-724) micromol/l when first seen in hospital, and 134 (94-219) micromol/l following the withdrawal of drug therapy and fluid replacement. In conclusion, volume depletion causing acute renal failure in patients taking ACE inhibitors is not uncommon. Such patients and their general practitioners should be aware that reversible renal impairment may occur during intercurrent illnesses, particularly if characterised by diarrhoea and/or vomiting.

High incidence of renal failure requiring short-term dialysis: a prospective observational study.

BACKGROUND: Previous estimates of incidence of acute renal failure (ARF) requiring renal replacement therapy have varied from 18 to 75 patients per million per year, but have been beset by problems of definition. AIM: To investigate whether the '90-day rule' provides a more reliable, reproducible and robust estimate of the need for short-term dialysis. SETTING: District general hospital serving a population of 147 000. DESIGN: Prospective observational study. METHODS: Patients who received renal replacement therapy in Dumfries and Galloway between 01/01/94 and 31/12/2000 were divided into two groups: long-term dialysis (> or =90 days) and short-term dialysis (<90 days). RESULTS: Of 302 patients, 193 received short-term dialysis, giving an incidence for short-term dialysis of 187 patient episodes per million per year (95%CI 170-203). Use of a more conventional definition for ARF (including all ARF and acute-on-chronic renal failure, but excluding patients with chronic renal failure who present acutely) produced a similar estimate at 176 patients per million per year (95%CI 160-193). DISCUSSION: The 90-day rule estimated the incidence of short-term dialysis/ARF at nearly twice the incidence of chronic renal failure requiring dialysis, and more than twice the most recent estimate of the incidence of ARF in the UK. The main attraction of the 90-day rule is its simplicity. If the high level of short-term dialysis/ARF found in our study is confirmed by other centres, there are significant resource implications for the provision of renal care.

Myocardial infarction in men and women under 65 years of age: no evidence of gender bias.

We examined short and long term outcomes of MI in a consecutive series of 169 men and 50 women who were followed for an average of 3.5 years. Similar percentages of men and women were admitted to medical intensive care, received in-patient cardiac rehabilitation, quit smoking at one year, were still smoking, were taking a lipid lowering drug or had returned to work at one year, underwent coronary angiography at 3.5 years or had died by 3.5 years. The lack of gender difference in outcome may reflect an absence of gender bias in the management of men and women with MI in southwest Scotland.

Population implications of lipid lowering for prevention of coronary heart disease: data from the 1995 Scottish health survey.

OBJECTIVE: To determine the proportion of the population, firstly, with cholesterol >/= 5.0 mmol/l and, secondly, with any cholesterol concentration, who might benefit from statin treatment for the following: secondary prevention of coronary heart disease (CHD); primary prevention at CHD risk 30%, 20%, 15%, and 6% over 10 years; and primary prevention at projected CHD risk 20% over 10 years (CHD risk at age 60 years if actual age < 60 years). SUBJECTS: Random stratified sample of 3963 subjects aged 35-64 years from the Scottish health survey 1995. RESULTS: For secondary prevention 7.8% (95% confidence interval (CI) 6.9% to 8.6%) of the population with cholesterol >/= 5.0 mmol/l would benefit from statins. For primary prevention, the prevalence of people at CHD risk 30%, 20%, 15%, and 6% over 10 years is 1.5% (95% CI 1.2% to 1.9%), 5.4% (95% CI 4.7% to 6.1%), 9.7% (95% CI 8.8% to 10.6%), and 32.9% (95% CI 31.5% to 34.4%), respectively. At projected CHD risk 20% over 10 years, 12.4% (95% CI 11.4% to 13.5%) would be treated with statins. Removing the 5.0 mmol/l cholesterol threshold makes little difference to population prevalence at high CHD risk. CONCLUSIONS: Statin treatment would be required for 7.8% of the population for secondary prevention. For primary prevention, among other factors, guidelines should take into account the number of patients needing treatment at different levels of CHD risk when choosing the CHD risk to target. The analysis supports a policy of targeting treatment at CHD risk 30% over 10 years as a minimum, as recommended in current British guidelines, with a move to treating at CHD risk 15% over 10 years as resources permit.